When the subject turns to cosmetic surgery, at least among North Americans, two things seem sure to happen -- laughter and embarrassment.

Laughter because many of the icons of surgical alteration -- Michael Jackson, Janet Jackson, Pamela Anderson -- are so distorted as to make us nervous, or their efforts to super-size their body parts seem downright amusing. Embarrassment because so many of us have either thought about undergoing cosmetic surgery or have actually done so.

So is cosmetic surgery simply vain and self-indulgent and therefore immoral? No.

American attitudes about cosmetic surgery are very much a product of American culture. Compare U.S. Presidential candidate Sen. John Kerry with Italian Prime Minister Silvio Berlusconi. Kerry has denied rumors that he's used Botox to ease wrinkles on his forehead. Perhaps he fears that such a disclosure -- if true -- would make him the target of both humor and embarrassment.

As for Berlusconi, he has a lot to be embarrassed about these days but getting a face lift did not faze him in the least. He took a month off to get it done and has been proudly mugging the results ever since.

Indulgence? Need?
Even more evidence that our Puritanical past is still alive and well when it comes to surgically tweaking yourself to enhance your looks comes from Brazil. Many Americans who electively undergo the knife deny it. They would no more fess up to a face lift, nose job or liposuction then they would the commission of a major felony. Not so in Brazil. Plastic surgery clinics appear like Starbucks on street corners. If you are wrinkled, unhappy with the size of something or fear some part of you is sagging, the Brazilian attitude is to get it fixed.

Where we see indulgence and vanity, they see only need and reasonableness.

All of which brings me to a conversation I recently had with parents whose child has Down syndrome. We all know the classic look of this genetic disorder. My friends worried about other kids reacting negatively to that look and wondered if they should send their child to a plastic surgeon to have his appearance surgically altered.

There is some evidence that kids, especially teen-agers, react negatively to how a child with Down syndrome looks. But there does not seem to be much evidence about how affected kids think about how they look. Surgeons themselves are divided about how well they can alter the appearance of a child with the disorder.

But suppose there is a surgeon who could transform the appearance of a child with Down syndrome to a more "normal" look. Would it be wrong? Some might say it would be fine since a child with the disorder has an abnormal or disfigured face. But is that really the case? Couldn’t it be said that a kid with Down syndrome has one of a number of looks that human beings are born with?

The decision to try to alter the appearance of a person with Down syndrome would be cosmetic -- not reconstructive or therapeutic.

Maybe we should lighten up
I find myself thinking that altering the appearance of a youngster with Down syndrome, if that is what the child and the parents want, would be neither vain nor indulgent. And if that is true then why not admit that Botoxing a wrinkled brow or downsizing a large nose, while cosmetic, may be reasonable choices for some to make as well.

While we love to gossip about and even snigger at those who use cosmetic surgery, maybe we should lighten up a bit. Cosmetic surgery like anything else can be abused or misused, but is it always just unseemly vanity to want to look better?

Arthur Caplan is director of the Center for Bioethics at the University of Pennsylvania.